Abdominal aortic aneurysms are very common in elder population and their rupture is the important cause of death in the western countries. Atherosclerotic abdominal aneurysms result from a weakening of the aortic wall by the extension of the disease into the media. Destruction of elastic fibers and medial atrophy are prominent in the affected aortic wall. Recent studies demonstrated that molecular pathogenesis of aortic aneurysm was explained by the activation of matrix metalloproteinase. In contrast, cystic medial necrosis with fragmentation of elastic fibers is the most important histological feature for ascending aortic aneurysm. Atherosclerosis is important for the etiology of descending aortic aneurysm and its histological features are similar to that of abdominal aortic aneurysm. Cystic medial necrosis is also important for the etiology of aortic dissection. Close relationship between aortic dissection and diseases such as hypertension, Marfan syndrome and congenital bicuspid aortic valves are well known. Re-expansion of aneurysm due to the endoleak after stent-graft deployment is critical problems. Our autopsy case of stent-graft deployment for aortic aneurysm revealed mural thrombi formation at the surface of native aortic wall.

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Objective: The aim of this study is to compare the clinical efficacy and safety of two laser wavelengths and fiber types in endovenous laser ablation (EVLA) of saphenous varicose veins of the lower limb. Design: Multi-center prospective randomized non-blind clinical trial. Patients and Methods: From January 2007 to December 2011, 113 patients (113 limbs) with primary varicose veins were randomized into two groups. They were treated with radial 2ring fiber and 1470 nm laser in group I (57 limbs) and bare-tip fiber and 980 nm laser in group E (56 limbs) in order to ablate the saphenous vein. Vein occlusion rates at 12 weeks and pain in treated region were recorded as primary endpoint. Visual analogue scale (VAS) for assessment of pain, rates of bruising, complications and equipment failure were recorded as secondary endpoint of safety. Results: Occlusion rates at 12 weeks were 100% in both groups. Rates of pain (0% vs. 25.0%) and bruising (7.0% vs. 57.1%) were significantly lower in group I (p<0.0001). VAS of pain was significantly lower on postoperative day 1, day 5 and 2nd weeks in group I. Conclusion: Treatment of saphenous varicose veins by EVLA using a 1470 nm laser and a radial 2ring fiber resulted in comparable occlusion rates at 12 weeks and less postoperative pain and bruising than EVLA with a 980 nm laser and a bare-tip fiber.

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In this case study, we report the successful surgical treatment of a popliteal artery aneurysm (PAA) in a neurofibromatosis type 1 (NF-1) patient. A 51-year-old man with a history of NF-1 was referred consequent to a complaint of pain in his right leg. Computed tomography revealed a 3.5-cm aneurysm in the right popliteal artery (PA) and diffuse stenosis in the distal PA due to thromboembolism. Vasculopathy is uncommon in NF-1, with PAAs being particularly rare. We selected a surgical approach to prevent rupture and limb ischemia. The aneurysm vessel wall was very fragile because of NF-1 and the aneurysm had extended to the middle superficial femoral artery. Therefore, we performed a femoral–anterior tibial artery bypass using a reversed saphenous vein graft and a ligation via an endovascular technique-assisted medial approach to exclude the aneurysm.

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Even though endovascular treatment for chronic total occlusion (CTO) of peripheral arterial disease is challenging, subintimal angioplasty (SIA) has proven to be an effective procedure. However, SIA cannot cross CTO lesions because of the inability to reinsert the guidewire into the distal true lumen in some cases. We herein describe the case of a 67-year-old male patient who was admitted to our hospital with intermittent claudication due to the CTO of the left external iliac artery. We attempted to cross the CTO using a SIA technique, but the guidewire could not reenter the true lumen. Therefore, by using a controlled antegrade and retrograde subintimal tracking (CART) technique, we treated the CTO of the left external iliac artery with stenting. When using the CART technique, there is no need for extension of the subintimal dissection beyond the occluded lesion, which might be useful technique for the CTO lesions.

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Popliteal venous aneurysms are an uncommon but potentially life-threatening disease as they can be a source for pulmonary thromboembolism. We report a surgically treated case of a popliteal venous aneurysm as a cause of fetal pulmonary thromboembolism. A 56-year-old woman was admitted because of acute dyspnea. After the admission, she went into cardiopulmonary arrest. Basic cardiopulmonary resuscitation was not effective. She had to be resuscitated with percutaneous cardiopulmonary support. Contrast-enhanced computed tomography revealed pulmonary thromboembolism and a popliteal venous aneurysm, which appeared to be a cause of the pulmonary thromboembolism. Thrombolytic therapy with recombinant tissue plasminogen activator was performed immediately. Temporary inferior vena cava filter was placed, and anticoagulant therapy was started. After her condition became stable, tangential aneurysmectomy and lateral vein reconstruction were performed. She received anticoagulant therapy with warfarin consecutively. Six months postoperatively, contrast-enhanced computed tomography showed popliteal venous patency without recurrences both venous aneurysm and pulmonary thromboembolism.

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A 53-year-old man with untreated diabetes presented with gangrene of the left foot. Computed tomographic angiography revealed stenosis and occlusion from the distal aorta to the bilateral common iliac arteries. Although stenting from the aorta to the right common iliac artery was successful, occlusion of the left common iliac artery persisted as a result of wire passage failure during a prior endovascular therapy attempt. Consequently, surgical reconstruction of the occlusive lesion was performed in our hospital. The stent was removed and endarterectomy of the distal aorta and the bilateral common iliac arteries was performed. The affected portion of the left foot was almost healed 5 months after the operation despite the need for debridement and split-thickness skin grafting. Although bypass grafting is usually chosen as a surgical option for aortoiliac occlusive disease, aortoiliac endarterectomy is an alternative plan in some cases of localized lesions that are limited to the distal aorta and proximal iliac arteries or when surgeons hesitate to use prosthetic grafts due to a high risk of infection.

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We report a case of chronic occlusion of the brachial artery treated with bypass surgery using an upper arm basilic vein in an in situ fashion. A 75-year-old woman had two years history of intractable skin ulcer and rest pain of the left fingers. Computed tomography revealed occlusion of the proximal part of the left brachial artery and insufficient run-off to the forearm because of small collateral arteries. Arterial reconstruction was performed using the basilic vein of the upper arm in an in situ fashion. After this operation, forearm circulation restored and the skin ulcer healed in a month.

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Group B Streptococcus (Streptococcus agalactiae) causes sepsis in pregnant women and neonates. On the other hand, infected aneurysms caused by Streptococcus agalactiae are very rare. We report the case of a 65-year-old man with a Streptococcus agalactiae-infected aneurysm of the brachiocephalic artery who suffered several cerebral infarctions before surgery. The patient was admitted because of pain in his right shoulder and loss of appetite that persisted for a month. On admission, he had no fever. His white blood cell count was 11,000/μl and serum C-reactive protein level was 3.72 mg/dl. Echocardiography revealed moderate to severe aortic regurgitation, and no vegetation was detected. Two days after admission, he developed high fever. The infected aneurysm of the brachiocephalic artery (41 mm in diameter) was diagnosed by enhanced computed tomography, and blood cultures were found to be positive for Streptococcus agalactiae. He subsequently developed left hemiparesis. Magnetic resonance imaging revealed new multiple cerebral infarctions in the right cerebral hemisphere, and he was treated with antibiotics for an additional week. Thirteen days after admission, surgery was performed. Under cardiopulmonary bypass, deep hypothermia, and selective cerebral perfusion, the infected aneurysm of the brachiocephalic artery was resected and aortic arch replacement with a rifampicin-soaked Dacron graft and aortic valve replacement were performed. The graft was covered with an omentum flap. Pathological examination revealed no bacteria on the aortic cusps, although accumulation of histiocytes with multinucleated giant cells and neutrophils was observed, which was consistent with infective endocarditis. His postoperative course was uneventful. Intravenous antibiotics were continued for 6 weeks after surgery. The patient has remained asymptomatic for 8 months after surgery.

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Infected aortic aneurysm are rare, but life-threatening and associated with a high risk of rupture. A case of infected aortic aneurysm caused by Streptococcus agalactiae is reported. A 60-year-old man was admitted to our hospital due to fever, neck pain and back pain after dental treatment. His white blood cells and C-reactive protein were elevated and Streptococcus agalactiae was isolated from blood cultures. One week later, computed tomography (CT) revealed aortic arch aneurysm. He was diagnosed of infected aortic aneurysm. He underwent resection of the aneurysm and in situ prosthetic graft replacement and omentopexy around the graft after antibiotic therapy for 3 weeks. Antibiotic agents were administered for 6 weeks postoperatively. The postoperative course was uneventful with no infectious complication.

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A 77-year-old man who underwent graft replacement of abdominal aorta presented with disorientation on postoperative day 20. Laboratory data showed high CRP (16.8 mg/dl). Computed tomography proved fluid retention and air around the prosthetic graft. We diagnosed abdominal aortic graft infection and performed resection of the whole infected graft, in-situ graft replacement of abdominal aorta, and omental wrapping. Antibiotics was rubbed around the graft and fixed by fibrin glue. Bacteroides fragilis was identified in preoperative blood culture and intraoperative fluid culture. The postoperative course was well and no reinfection had been occured for last 7 months. In the case of abdominal aortic graft infection, we never forget the possibility of anaerobic bacterialinfection and should adopt the suitable method of microbial culture and select optimal antibiotics.

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Pseudoaneurysms of the common femoral artery are typically caused by endovascular interventions or surgical procedures. In contrast, femoral artery pseudoaneurysms due to blunt trauma are rare. We report here a pseudoaneurysm of the common femoral artery diagnosed incidentally 10 years after the blunt inguinal trauma. A 65-year-old man consulted our hospital for his abdominal discomfort. He had no history of diabetes mellitus, coronary artery or cerebrovascular disease. Computed tomography of the abdomen revealed a pseudoaneurysm of the left common femoral artery measuring 50 mm in diameter with massive intramural thrombus. No other associated aneurysms were found. He had experienced an event of blunt left inguinal trauma followed by hematoma formation with subsequent swelling and pain approximately 10 years before. Although he had not gone to hospital for treatment, the hematoma had disappeared gradually. At this presentation, he had no symptoms related to venous or nervous compression and no clinical signs of distal emboli. To avoid rupture or limb ischemia, operation was performed under general anesthesia. The pseudoaneurysm was treated successfully with graft replacement with a 10 mm knitted Dacron graft. The postoperative course was uneventful.

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A popliteal venous aneurysm is a rare diagnosis, however it has been frequently recognized to be sources of a pulmonary embolism. A 48-year-old man, previously healthy, was admitted by an acute respiratory disturbance. Computed tomography (CT) showed the bilateral pulmonary emboli and a left popliteal venous aneurysm, 35 mm saccular. He recovered after following conservative treatment. Magnetic resonance imaging and duplex scanning showed a venous aneurysm with an image defect of the left popliteal vein. Aneurysmectomy and end-to-end anastomosis was performed. Although the popliteal venous blood flow has been checked by duplex scanning and enhanced CT, elasticity stocking wear and an anticoagulant therapy were needed for leg edema postoperative half a year, no episodes of pulmonary embolism.

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